Radioembolization paper publication a “landmark moment” for IR-Hepatology collaboration

Journal of Hepatology June 2020 front cover

The cover of June’s edition of the Journal of Hepatology featured a paper on transarterial radioembolization for the treatment of hepatocellular carcinoma (HCC). Publication of the paper, authored by Riad Salem (Department of Radiology, Northwestern University, Chicago, USA) and colleagues, has been described as a “milestone” for interventional radiology (IR) as a specialty and has heralded a call for greater collaboration between interventional radiologists and their Hepatology colleagues.

In the paper, Salem and colleagues investigate lung shunt function (LSF) observed in early HCC, and provide the scientific rationale for eliminating this step from routine practice. Salem and colleagues found that early stage patients, where segmental injections are planned, exhibited low lung shunting, effectively eliminating the risk of radiation pneumonitis. The study team proposed that the lung shunt study be eliminated in this subgroup, leading to fewer procedures, a cost reduction, and improved convenience for patients.

Riad Salem

Commenting on the clinical implication of eliminating lung shunt function in early HCC patients from routine practice, Salem tells this newspaper that “this would streamline the Yttrium-90 [Y90] algorithm, decrease the time to treatment, lower costs and minimise unnecessary hospital visits.” He continues: “This is particularly important in the time of COVID-19. Basically, we could take a patient selected for segmental Y90 at tumour board, schedule the procedure, and treat. This model also gets us one step closer to our ultimate goal of the ‘one-hour Y90’ as the standard of care.”

Julius Chapiro, co-director of the Interventional Oncology Research Laboratory at Yale School of Medicine, New Haven, USA, speaks to Interventional News about the publication of the data, and why its publication in one of the preeminent journals for research into the field of hepatology represents a landmark moment in the continuing development of interventional radiology (IR). He argues that the paper could help to forge stronger ties between interventional radiologists and their colleagues in hepatology.

Julius Chapiro

“The importance of publishing such data in the Journal of Hepatology and being featured as the cover story cannot be overstated for all of interventional radiology,” Chapiro comments. He cites the words of IR pioneer Charles Dotter, calling upon the practice to “provide clinical care” and “own” diseases and patients. “If we fail to do so,” Chapiro says, paraphrasing Dotter, “[we] become nothing more than high-priced plumbers”.

According to Chapiro, the manuscript takes these words from Dotter directly to heart. “Those of us who advocate for interventional oncology as the fourth pillar of cancer care must be rooting for Riad Salem’s team and this achievement,” he says. “Such high profile publications are changing clinical paradigms and inform a broad variety of specialists involved in therapy of liver cancer. The Journal of Hepatology is the official outlet of the European Association for the Study of the Liver (EASL) and has the highest impact factor of all journals focusing on liver disease. The publication reaches tens of thousands of people across the globe, including medical and surgical oncologists, both academic and in private practice. Having an IR cover story highlight our entire profession with such prominence legitimises our efforts, advocates for our therapies, establishes unquestionable authority, and protects our specialty.”

Describing the publication process, Salem says: “Once we had selected the prestigious Journal of Hepatology as our target, the manuscript was formatted accordingly and submitted. After receiving generally positive comments, we were encouraged to submit a revision with specific queries addressed. Once it was accepted, their production team sprang into action and enhanced the presentation style and graphics. They are a world-class team that significantly improved the manuscript quality, with the end result of the journal cover.

“The field of Hepatology is supremely competitive. Research groups from all around the world compete for a place in their high impact journals, with the Journal of Hepatology as one of the leaders, with an impact factor of 19. If the research is novel, impactful, and advances the field, the editors are universally fair and provide opportunities for all disciplines to publish in their journal. I have been very fortunate that in my career advancing IR, 26 manuscripts have been published in the highest impact journals of Gastroenterology, Hepatology, Journal of Hepatology and Gut. The editors placing our study on the cover reflects an acknowledgment of our team dedicating years of hard work investigating new concepts and challenging dogma. Our research group is humbled and honoured by this prestigious recognition.”

Discussing the efforts being made to improve teamwork between hepatologists and interventional radiologists, Chapiro comments that interventional radiologists are an integral part of liver tumour boards across most academic institutions, and that there has been a growing appreciation of their role in treating cancers of the liver. “Hepatologists and medical oncologists, who mostly lead those tumour boards in their cancer centres, have come to appreciate interventional oncologists as valuable team members and the spirit of those interactions is usually collaborative, productive, and cordial,” Chapiro states.

However, he argues that one of the most prevalent issues for interventional radiologists during these interactions with hepatology colleagues is the lack of unequivocal data in support of the therapeutic options. “This is especially true for the relative paucity of prospectively collected data from randomised controlled trials (RCTs) that would support the use of Y90, for example, in lieu of chemoembolization or as an option for patients with advanced stage disease.” Although not a randomised controlled trial, the data from Northwestern published in J Hep on the use of Y90 in early stage disease in patients waitlisted for transplant is an extremely valuable piece of information and has huge practical value, Chapiro suggests. “The elimination of shunt studies will make it more likely for transplant hepatologists and medical oncologists to choose this therapy, now that it has the stamp of approval from J Hep. Such data represent an important bridge between IR and other members of the tumour board.”

Exploring this idea further, Chapiro’s abiding message is that “teamwork begins at home”. “Our own institution has a very productive liver centre and interventional radiologists participate as full and associate members in collaborative projects and National Institute of Health [NIH]-funded research,” he says, adding that other avenues to collaborate are certainly through participation in NCCN guidelines, and through active memberships in national and international societies such as the American Association for the Study of the Liver Disease (AASLD), EASL and several Asian societies. Looking ahead at the opportunity for further opportunities to collaborate, he called for interventional radiologists to continue to make their voices heard within hepatology practice. “It is key for us to be present at their annual meetings and invite them to our own platforms such as the Society of Interventional Oncology Annual Meeting. At the end of the day, all we care about are patient outcomes and there is no better glue for us than this shared responsibility.”


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